BACKGROUND: Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults. OBJECTIVE: To identify the best single and pair of mental status test items that predict the presence of delirium. DESIGN, SETTING: Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center. METHODS: Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis. RESULTS: Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%). CONCLUSIONS: We identified a single item with > 80% and pair of items with > 90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.

BACKGROUND: Difficulties with performance of functional activities may result from cognitive and/or physical impairments. To date, there has not been a clear delineation of the physical and cognitive demands of activities of daily living. OBJECTIVES: To quantify the relative physical and cognitive demands required to complete typical functional activities in older adults. DESIGN: Expert panel survey. SETTING: Web-based platform. PARTICIPANTS: Eleven experts from 8 academic medical centers and 300 community-dwelling elderly adults age 70 and older scheduled for elective noncardiac surgery from 2 academic medical centers. METHODS: Sum scores of expert ratings were calculated and then validated against objective data collected from a prospective longitudinal study. MAIN OUTCOME MEASUREMENTS: Correlation between expert ratings and objective neuropsychologic tests (memory, language, complex attention) and physical measures (gait speed and grip strength) for performance-based tasks. RESULTS: Managing money, self-administering medications, using the telephone, and preparing meals were rated as requiring significantly more cognitive demand, whereas walking and transferring, moderately strenuous activities, and climbing stairs were assessed as more physically demanding. Largely cognitive activities correlated with objective neuropsychologic performance (r = 0.13-0.23, P < .05) and largely physical activities correlated with physical performance (r = 0.15-0.46, P < .05). CONCLUSIONS: Quantifying the degree of cognitive and/or physical demand for completing a specific task adds an additional dimension to standard measures of functional assessment. This additional information may significantly influence decisions about rehabilitation, postacute care needs, treatment plans, and caregiver education. Published by Elsevier Inc. All rights reserved.